SOCRATES: Thinking About Pain

When I was in medical school one of the most useful mnemonics I came across was "SOCRATES". The mnemonic is designed to figure out the characteristics of someone’s pain. The characteristics of pain help the clinician develop a differential diagnosis from which testing can be ordered, and then hopefully, treatment can be given.

So what does each letter in the mnemonic SOCRATES stand for??? Let’s go letter by letter…

S   O   C   R   A   T   E   S

The first “S” stands for “site”. What body part or parts are involved? Is the pain in the leg? Is it in the abdomen? Is it a general sense of overall discomfort? The site of pain helps you fine tune your subsequent physical exam and diagnostic decision making.

The next letter is “O”, which stands for “onset”. When did the pain start? Asking about the onset of the pain is extremely important! For example, if someone has had chronic low back pain for 10 years that invokes a much lower sense of urgency than someone complaining of the sudden onset of severe belly pain or headache.

S O C R A T E S 

S – Site
O – Onset
C – Characteristics
R – Radiation
A – Associated
T – Timing
E – Exacerbating/
S – Severity

“C” stands for “characteristics”. What are the characteristics of the pain? You want the patient to describe the pain in their own terms without influencing them too much. The pain may be sharp, dull, heavy, burning, etc, or a combination of descriptors.

The next letter is “R”, which represents “radiation”. I typically ask if the pain stays at the site or if it travels somewhere else in the body. For example, someone with chest pain radiating to the left arm might be experiencing a heart attack. Back pain that is associated with radiation down the leg might indicate a herniated lumbar disc that may require surgery. Back pain radiating to the abdomen could be intraabdominal pathology. Radiation of the pain is an important component to help guide your decision making.

“A” stands for associated symptoms. What other symptoms are present with the pain? For example, if the patient is complaining of belly pain do they also have nausea or vomiting? If they have a headache do they also complain of double vision or photophobia? Associated symptoms can provide a wealth of information to help you hone your differential diagnosis even more.

“T” stands for timing. When does the pain occur? Does it happen at specific times of the day, or is it constant? Does it happen during a certain movement? All of these can give you an idea of the origin for the pain.

The letter “E” represents “exacerbating” factors; grouped within this is also alleviating factors. The patient should be probed as to what makes their pain better or worse. Certain physical positions, medications, etc. may make the pain better or more unbearable. These factors can all provide historical clues about the root cause.

The final “S” stands for “severity”. In most hospitals this is formulated on a 1 to 10 scale with 10 being the most severe pain they’ve ever experienced. This can be a tricky one to gauge because many patients will describe 10 out of 10 pain when they are lying comfortably in bed; therefore, it is often necessary to ask more pointed questions and place pain in a context.

Overall, the answers obtained when using the mnemonic SOCRATES can provide a solid framework from which to order new testing and treatments.

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The Dumbing Down of Medical Education: A Critical Look at Our History

It is quite likely that this article will make me sound old and cynical, as in – “I walked uphill to school in the snow both ways and so should you…”, but my intention is not to be any of these things, but rather to bring to light some important issues in the work ethic of doctors, and perhaps more generally, in our society as a whole.

It seems that health care education, at both the medical school and resident level, needs to be tinkered with, again. But before I go any further, let me give you a little background information as to why I think this is the case…

Medical education in the United States took a huge step forward at the beginning of the 20th century. Under the leadership of medical greats like Sir William Osler and Harvey Cushing, the Johns Hopkins University became the sine-qua-non of medical education in the early 1900s.

Prior to this, the best medical schools in the world were mostly in Europe. In fact, many American physicians made medical “pilgrimages” to see surgeons and physicians diagnose and treat disease throughout the European continent (especially Britain and Germany). The European model of medical education was rigorous, well designed, and well executed.

It wasn’t until the Flexner Report came out in 1910 that the United States overtook Europe as the premiere training ground for future doctors. The Flexner report, written by Abraham Flexner, made important recommendations about how medical education should be structured in the United States.

From that report, medical school admission and curricula in the United States became more rigorous and standardized. Perhaps more importantly, it created generations of physicians and surgeons who were extremely well trained.

Several tweaks here and there created the medical system that the United States knew for most of the 20th century. All doctors went through a rigorous four years of medical school, followed by even more rigorous residency training. Medicine was a calling; if you weren’t up to the task you either quite, or weren’t allowed to finish.

Fast forward to the late 20th and early 21st century… New York State has passed a law – known as the Libby Zion Law – that restricts work hours on residents to less than 80 hours per week. Prior to this, residents were called “residents” because they “resided” in the hospital, frequently spending over a hundred hours a week taking care of patients.

The purpose of being a resident was to see and treat as many patients and diseases as possible. The more cases you saw, the better equipped you were to practice medicine confidently, independently, and most important capably.

In 2003, when the 80 hour work week became the “standard” in resident education across the country it forced physicians-in-training to work fewer hours than they normally would. Prior to this, medical students and residents took care of their patients from admission to discharge. The new restrictions forced doctors to “sign-out” medical coverage and decision making to the next “shift” of physicians coming on call. The paradigm for training a physician became less about the calling of medicine and more about shift work.

So what’s the big deal? At this point, it seems to make sense… If doctors are less tired they should make fewer errors, right? Wrong! Since the 2003 standards few studies have shown that patients do better under the new work hour restrictions. In fact, it is not uncommon for more errors and additional, and frequently un-needed, testing to occur while the “covering” physician is in charge of the patient’s care. This is because the doctors who receive “sign-out” usually do not know the patient as well as the admitting doctor.

I would contend (albeit a controversial stance) that the work hour restrictions are inadvertently creating a generation of shift workers who are comfortable “signing-out” their patients to the on call doctor. Whoaaa, pump the brakes! I know that I am using some pretty inflammatory language, and many of you will not agree, but…

This generation of medical students and residents have been forced (and the reason I say forced is that many medical trainees today would certainly survive the brutal training of the past) to be less invested in taking care of their patients. Instead, they are being trained to be more concerned about getting “out on time” so their training programs are not sanctioned.

As a result, medical education in the United States has become a fragmented time line of admitting some patients, treating different patients, and then discharging others. The traditional method of seeing a patient, working up their complaint, offering a treatment, seeing if it works or not, and then following them through their hospital course has become a thing of yesteryear (or perhaps yester-century). However, I feel strongly that the process of seeing, treating, and following “your” patients is vital to forming the clinical judgment necessary to create a great (and yes I use the term “great” deliberately) doctor.

Before I finish my rant I will leave you with an analogy… Doctors used to be the Navy Seals of the health care team. They were better trained and worked harder and longer than anyone else in health care. Their training allowed them to think outside the box and problem solve difficult cases.

Unfortunately, medical education for physicians in the United States is being “dumbed down”. We need to bring back the days of medicine as a calling, as a right of passage that not everyone is, nor should be, capable of completing. It is time to re-claim our rights to being the best and brightest, and to regain our status as the best medical training ground in the world. But we can only do that through hard work and perseverance, not by punching a time card.

References and Resources

(1) Brensilver JM, Smith L, Lyttle CS. Impact of the Libby Zion case on graduate medical education in internal medicine. Mt Sinai J Med. 1998 Sep;65(4):296-300.

(2) Jones AM, Jones KB. The 88-hour family: effects of the 80-hour work week on marriage and childbirth in a surgical residency. Iowa Orthop J. 2007;27:128-33.

(3) Kramer M. Sleep loss in resident physicians: the cause of medical errors? Front Neurol. 2010 Oct 20;1:128

(4) Irby D. Educating physicians for the future: Carnegie’s calls for reform. Med Teach. 2011;33(7):547-50.

(5) Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation-Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff: A Randomized Trial. JAMA Intern Med. 2013 Mar 25:1-7.